The Combined Oral Contraceptive Pill Versus Bromocriptine to Puerperal Fever

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					      The Combined Oral Contraceptive Pill Versus
  Bromocriptine to Suppress Lactation in Puerperium : A
            Randomized Double Blind Study
                                         Manee Piya-Anant MD*,
                            Suporn Worapitaksanond MA*, Kitinan Sittichai BA*,
                              Porndara Saechua BA*, Anantaporn Nomrak BA*

 * Department of Obstetrics and Gynaecology, Faculty of Medicine, Siriraj Hospital, Mahidol University

         A randomised double blind comparative study of 230 HIV infected mothers who had a normal
delivery at 37-42 weeks’ gestation were divided into two groups; 116 combined pill users and 114
bromocriptine users to suppress lactation. There were 33 cases (28.5%) of combined pills users and 29 cases
(25.4%) of bromocriptine users who had breast engorgement without statistical difference. All of them had
mild breast engorgement without any treatment except one case (0.9%) in the bromocriptine group had
severe breast engorgement with puerperal fever and needed an analgesic drug. There were no side effects of
the drugs. This study showed that combined pills were beneficial to suppress lactation in HIV infected
mothers to prevent postnatal mother-to-child transmission because of low risk and low cost.

Keywords : Suppress lactation, Combined pills, Bromocriptine, HIV infected mother, Breast engorgement

J Med Assoc Thai 2004; 87(6): 670-3

Rationale                                                    Thailand, our national policy is to avoid breast-
          Transmission of Human Immunodeficiency             feeding to prevent postnatal transmission from HIV
Virus (HIV) from mother to child is a large problem in       infected mother so that suppression of lactation in
obstetrics. Vertrical transmission during pregnancy          the puerperal is needed.
and labour has been reported at 24% - 38.5%(1-4). There                Prolactin level is high during the early
are many reports of postnatal transmission during            postpartum period. Prolactin will stimulate milk
breast feeding(5-7). Breast milk transmission of HIV-1       production within 3-4 days of delivery so that breast
can occur at any time during the entire duration of          engorgement will last about 48-72 hours(11). Mothers
breastfeeding. The risk of late postnatal transmission       with breast engorgement usually experience pain and
(after 2.5 months of age) is 3.2 per 100 child/years of      fever so suppression of lactation can prevent these
breastfeeding(8). Mastitis, an inflammation of the           symptoms.
breast, has recently been linked to a higher human                     There are many methods to suppress
immunodeficiency virus load in breast milk (9).              lactation. Breast binding can decrease stimulation of
Avoidance of breastfeeding can prevent postnatal             the nipple and the milk ejection reflex but 60% of
transmission to a child who may not be infected.             lactating mother still had breast engorgement from
However, countries where the risk of death in the first      day 3-5 postpartum(12). High dose estrogen reduces
year of life is 50% from diarrhea and other diseases         lactation in 86% (13) but increses the risk of postpartum
(excluding AIDS) breastfeeding is still the feeding          thromboembolism by three times that of postpartum
method of choice. Clemen(10) reported that infants in        thromboembolism(14). Bromocriptine has been used
whom breastfeeding was initiated early had a 20%             worldwide since 1980 for the prevention of breast
lower rate of diarrhea than in those initiated late. In      engorgement in the puerperium(15). A comparative
                                                             study between high dose estrogen and bromcriptine
Correspondence to : Piya-Anant M, Department of Obstetrics   showed that bormocriptine had a better outcome(12).
and Gynaecology, Faculty of Medicine, Siriraj Hospital,
Mahidol University, Bangkok 10700, Thailand.
                                                             Many reports(15-17) showed that using bromocriptine

J Med Assoc Thai Vol. 87 No.6 2004
during the puerperium increases the risk of                clinical and demographic characteristics of both
vasospasm especially in those with pregnancy               groups were similar (Table 1). The average age was
induced hypertension. At present, the use of prophy-       23.2 + 4.6 years in combined pill users and 24.3 + 5.1
lactic antiretroviral treatments has brought about a       in bromocriptine users. Body mass indices were 25.1
dramatic decrease in the risk of transmission(18) but      + 4.7 and 24.9 + 4.0 kg/m2 respectively. The obstetric
have shower progress in ablactation.                       histories of both groups were also similar; The
                                                           majority were primigravida and, the gestational age
Objective                                                  of the pregnancy was 39.4 + 1.6 and 38.8 + 1.5 weeks
          To compare the effect outcome of bromocrip-      in the combined pill group and the bromocriptine
tine and a combined oral contraceptive pill containing     group respectively. There were 33 cases (28.5%) of
50 micrograms ethinyl estradiol in the supression of       breast engorgement in the combined pill users and 29
lactation in the puerperium.                               cases (25.4%) in the bromocriptine users (Table 2). In
                                                           the combined pill group, there were 0.9%, 3.4%, 10.3%,
Material and Method                                        9.5% and 4.3% who had breast engorgement on the
          A randomised double blind comparative            first day, second day, third day, fourth day and fifth
study of 230 asymptomatic HIV infected mothers             day after delivery respectively. In the bromocriptine
aged between 18-35 years. All subjects had a normal        group, there were 1.8%, 4.4%, 7.9%, 7.9% and 3.5%
delivery at 37-42 weeks’ gestation and were willing        who had breast engorgement on the first day, second
to participate in this study and signed the consent        day, third day, fourth day and fifth day respectively.
form. The subjects were randomised by computer to          All of them had mild breast engorgement except one
either bromocriptine or a combined pill containing         in the bromocriptine group who had severe breast
50 micrograms of ethinyl estradiol two tablets twice       engorgement and needed analgesics (Table 3). There
a day for 5 days. Both drugs were put into the same        were no side effects of the drugs seen in this study.
type of capsule so that both patient and doctor were
“blind” to the treadment. The first dose of drug was
given within 12 hours of delivery. Signs and symptoms
of breast engorgement and any side-effects of the          Table 1. Characteristics of women in the study according to
                                                                    type of medication. Received figures are percentage
drugs were recorded daily by a different group of
doctors and nurses until 12 hours after the last dose.     Characteristic             Combined pills            Bromocriptine
The degree of breast engorgement was identified as                                       N = 116                   N = 114
mild or severe. Mild breast engorgement was defined
as generalized tenderness and/or generalized swelling      Age (year)                   23.2    +   4.7          24.3   +   5.1
                                                           BMI (Kg/m 2 )                25.1    +   4.7          24.9   +   4.0
with heat of the breast. Severe breast engorgement was
                                                           Gestational age (week)       39.4    +   1.6          38.8   +   1.5
defined as generalized tenderness and/or generalized       Abortion                      0.7    +   0.4           0.7   +   0.5
swelling with heat plus puerperal fever.                   Gravida                       1.7    +   0.9           1.8   +   0.9
          The exclusion criteria were
          1. Subjects at high risk for taking a combined
pill with a high dose of estrogen were those more than
35 years old, overweight or with a past history of a
thromboembolic episode.                                    Table 2. Day that breast engorgement commenced according
          2. Subjects at high risk for taking bromocrip-            to the drug used to suppress lactation
tine were those with pregnancy-induced hypertension,                           Combined pill              Bromocriptine
seizure, stroke or myocardial infarction.                                        (n = 116)                  (n = 114)

Results                                                                        No.        %               No.           %
        From January 1997 to December 1998 there
                                                           First day             1        0.9              2             1.8
were 230 HIV infected mothers who delivered and            Second day            4        3.4              5             4.4
were willing to paticipate in this study. The subjects     Third day            12       10.3              9             7.9
were divided into two groups; 116 subjects took the        Fourth day           11        9.5              9             7.9
combined oral contraceptive pill and 114 subjects          Fifth day             5        4.3              4             3.5
took bromocriptine in order to suppress lactation. The     Total                33       28.5             29            25.4

J Med Assoc Thai Vol. 87 No.6 2004                                                                                             671
Table 3. Severity of breast engorgement according to drug             The authors concluded that combined oral
         used to suppress lactation                         contraceptive pill is beneficial to suppress lactation
Breast endorgement      Combined pills   Bromocriptine
                                                            in postpartum women such as HIV infected mothers,
                                                            because action of a combined pill similar to bromocrip-
                         No.     %        No.     %         tine but the cost of a combined pill was lower and the
                                                            side effects of a combined pill in Thai women were
Severe                    0       0        1      0.9       very low.
Mild                     33      28.5     28     24.6
None                     83      71.6     85     74.6
Total                   116     100.1    114    100.1       References
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                        ้      ่
ศึกษาเปรียบเทียบการยับยังการหลังน้ำนมของยาเม็ดคุมกำเนิดและ Bromocriptine


         การศึกษาเปรียบเทียบโดยวิธี randomised double blind ผลของยาเม็ดคุมกำเนิด (combined pill) และ
bromocriptine ในการยับยั้งการหลั่งน้ำนมในมารดาที่ติดเชื้อเอดส์ ที่คลอดปกติทางช่องคลอดเมื่ออายุครรภ์
37-42 สัปดาห์ จำนวน 230 ราย โดยแบ่งผู้ป่วยเป็น 2 กลุ่มโดย 116 รายใช้ยาเม็ดคุมกำเนิด และ 114 รายใช้
bromocriptine ในการยับยั้งการหลั่งน้ำนม จากผลการศึกษาพบว่า ร้อยละ 28.5 ในกลุ่มที่ใช้ยาเม็ดคุมกำเนิด
และร้อยละ 25.4 ในกลุ่มที่ใช้ bromocriptine ยังมีอาการนมคัดผลที่ได้ไม่แตกต่างกันทางสถิติ อาการนมคัด
ส่วนใหญ่มีอาการไม่มาก ยกเว้นหนึ่งรายคิดเป็น ร้อยละ 0.9 ในกลุ่มที่ใช้ bromocriptine มีอาการนมคัดมาก
จนต้ อ งใช้ ย าแก้ ป วด และจากผลการศึ ก ษาไม่ พ บอาการแทรกซ้ อ นของยา แสดงให้ เ ห็ น ว่ า ยาเม็ ด คุ ม กำเนิ ด
สามารถยับยั้งการหลั่งน้ำนมได้ดีอย่างน้อยเท่า bromocriptine แต่มีข้อดีกว่าเพราะยาเม็ดคุมกำเนิดราคาถูก

J Med Assoc Thai Vol. 87 No.6 2004                                                                                   673

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Description: The Combined Oral Contraceptive Pill Versus Bromocriptine to Puerperal Fever